Digital clinical teaching of cardiovascular surgery supported by precision imaging and 3D printing technology: a randomized parallel-controlled trial

Introduction

Cardiovascular surgery constitutes a critical component of surgical practice, given the intricate anatomy and hemodynamic mechanisms of the heart’s major vessels. A comprehensive understanding of the heart’s anatomy, including its valves and adjacent great vessels, as well as their interrelationships, requires conceptualization of three-dimensional (3D) spatial structures (1). Historically, medical education transitioned from the conventional lecture-based learning (LBL) model, characterized by passive knowledge transmission, to active learning frameworks including case-based learning (CBL), problem-based learning (PBL), and team-based learning (TBL). These approaches have been widely adopted to enhance students’ clinical reasoning and collaborative skills (2-5). A comprehensive understanding and technical proficiency in disease management are fundamentally rooted in human anatomy. Mastery of the anatomical structures of the heart, brain, liver, gallbladder, gastrointestinal tract, and other organs necessitates a highly developed capacity for 3D spatial visualization. The complexity and challenging nature of the subject matter are interrelated, resulting in students often experiencing apprehension due to the perceived difficulty and exhibiting diminished enthusiasm for learning. Currently, 3D modeling and 3D printing technologies, based on precision imaging, are rapidly advancing and being increasingly integrated into clinical education (6). Using the teaching of cardiovascular surgery as a case study, this paper investigates the enhancement of digital instructional methods in clinical medical surgery through the application of precision imaging and 3D printing technologies, which possess distinct typicality and representativeness. This study investigates an innovative model aimed at enhancing clinical surgical education through the application of digital technology. It is the first to incorporate 3D printing and advanced imaging techniques within the case-, problem, and team-based learning (C-P-TBL) hybrid teaching framework, effectively addressing the limitations of current learning models in spatial visualization training. Further details can be found in the subsequent report. We present this article in accordance with the CONSORT reporting checklist (available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-98/rc).

Methods

Participants

This study employed a parallel design randomized controlled trial (RCT) methodology. A computer-generated random sequence, produced using the software SPSS 26.0 (IBM Corp., Armonk, NY, USA), facilitated the allocation of 80 students undertaking internships in the Department of Cardiac and Great Vessels Surgery at The Second Hospital of Hebei Medical University. An independent statistician, who was not involved in the instructional or evaluative processes, executed the randomization procedure. The inclusion criteria were as follows: (I) the ability to systematically complete clinical internship; and (II) consent to participate in the study. The exclusion criterion was the inability to complete the study due to personal reasons. All instructional responsibilities were collaboratively undertaken by an associate professor and a lecturer. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study received approval from the Research Ethics Committee of The Second Hospital of Hebei Medical University (No. 2024-C090). Prior to the commencement of the clinical internship, oral informed consent was obtained from participants. This consent process was documented in the questionnaire administered at the conclusion of the clinical internship, with the completion of the questionnaire serving as reaffirmation of the participants’ consent to partake in the study. The cardiac computed tomography (CT) angiography data used for 3D modeling and printing were derived from anonymized clinical cases, with informed consent obtained from all patients. Students were allocated to either the digital teaching group or the C-P-TBL teaching group integrating CBL, PBL, and TBL approaches by means of random sampling based on their student numbers. Each group comprised 40 students, further subdivided into four subgroups of 10 students each, with one student appointed as the group leader.

Trial design

C-P-TBL teaching group

One week prior to the class, the teaching physicians disseminated theoretical knowledge and case data pertaining to the disease to the students. They posed questions regarding the diagnosis, treatment, and prognosis of the disease, including epidemiology, etiology, pathological anatomy, clinical manifestations, diagnosis, classification and staging, treatment principles, and the latest advancements in the field. Under the guidance of the group leader, the groups were instructed to fully utilize the knowledge and skills of each member. Members were encouraged to collaborate, consult textbooks, guidelines, and relevant literature, and engage in internal communication and discussion to independently resolve issues. The group then collectively summarized their findings and documented any unresolved issues or areas lacking consensus.

In face-to-face instruction, students engaged in problem-centered group discussions, wherein team members independently addressed most issues. During this process, the instructor provided minimal guidance and refrained from offering direct solutions to queries. Subsequently, different students presented case reports based on the discussion outcomes and systematically responded to questions ranging from clinical diagnosis and treatment to underlying pathological mechanisms. In conclusion, the educators provided feedback on each group’s presentations, augmented the discussion with pertinent knowledge points, and systematically synthesized the theoretical concepts.

Digital teaching group

Prior to the classroom instruction, cardiac multi-slice spiral CT angiography data from anonymized clinical cases of cardiovascular surgery patients (approved by the Ethics Committee) were processed for the digital teaching group. We selected three disease models, namely aortic valve stenosis, aortic valve insufficiency, and aortic aneurysm, from the previous case data for teaching implementation. These data were used to generate 3D reconstructions and 3D-printed heart models. The patients’ clinical profiles (e.g., age, diagnosis, and comorbidities) were incorporated into the teaching cases to simulate perioperative decision-making. The heart was imaged using multi-slice spiral CT, resulting in the acquisition of two-dimensional (2D) transverse images (Figures 1,2). The data obtained from cardiac multi-slice spiral CT scans were processed using the medical imaging software 3D Slicer (https://www.slicer.org/) to construct a 3D reconstruction model. Subsequently, a corresponding digital model of the heart was developed (Figures 3-8). This model was then encoded into a 2D format, enabling multi-angle visualization on multimedia platforms, including mobile phones and tablets. The data were processed and subsequently imported into the PolyJet 3D printer (Stratasys, Minnetonka, MN, USA) to facilitate the completion of the printing process. The heart model was fabricated using flexible transparent materials, whereas the internal structure was delineated with opaque materials to achieve a comprehensive 3D representation of the model (Figure 9).

Figure 1 Anatomical images of the aortic sinus.

Figure 2 The sinus of Valsalva and coronary arteries.

Figure 3 Import the 3D Slicer.

Figure 4 Segmentation and labeling of anatomical sites of 3D Slicer.

Figure 5 Valve reconstruction. Pink: mitral valve; blue, aortic valve.

Figure 6 Part of the reconstructed myocardium.

Figure 7 The reconstructed aortic root and coronary artery.

Figure 8 Three-dimensional reconstruction of the heart.

Figure 9 Three-dimensional printed heart appearance.

During the face-to-face instructional phase, under the supervision of the attending physician, students assumed a central role. Case discussions were conducted, with a designated representative from each group delivering presentations, whereas other group members contributed additional insights. This approach ensured active participation from all students. Through the integration of cardiac imaging, 3D printing of cardiac lesion models, and surgical procedures, a comprehensive understanding of the anatomy associated with various cardiac diseases was achieved. This approach encompassed procedures such as coronary artery bypass grafting, heart valve replacement, aortic dissection surgery, and artificial blood vessel replacement. The process involved the establishment of extracorporeal circulation, induction of cardiac arrest, intracardiac operations, heart recovery, parallel circulation, and cessation of extracorporeal circulation. This integration facilitated a detailed examination of the heart’s atrium, valve complex, aorta, and other anatomical components of the heart to achieve a comprehensive, multi-dimensional understanding. Using the anonymized patient’s clinical data (e.g., age, preoperative risk factors), students developed a perioperative strategy to simulate real-world clinical decision-making, emphasizing the integration of anatomical knowledge and patient-specific factors.

Evaluation

Objective evaluation

Following the internship, the impact of the research was evaluated through an examination process, which encompassed both theoretical and practical components. The theoretical assessment, conducted as a closed-book examination, emphasized knowledge of anatomical landmarks, disease classification, and treatment methodologies. It comprised 100 multiple-choice questions, each contributing to a 100-point grading scale, and accounting for 60% of the overall evaluation. The practical component assessed surgical operation skills, focusing on fundamental procedures and essential techniques. The skills assessment encompassed history taking, case analysis, cardiac physical examination, and pericardiocentesis, with a total score of 100 points, constituting 40% of the overall evaluation. A single instructor evaluated all procedures using a standardized scoring rubric, and an additional instructor oversaw the assessment process and verified the scores. The theoretical examination was developed by the leader of the clinical teaching team and submitted to the Academic Affairs Office for review and approval.

The theoretical examination was selected from the examination question bank of The Second Hospital of Hebei Medical University. The questions in this question bank were formulated in accordance with the framework of the national medical license examination and a strict standard process, and were implemented after being reviewed by the Academic Affairs Office and the Office of Postgraduate Education. The clinical skills scoring criteria followed the Objective Structured Clinical Examination (OSCE) standards. Since the group allocation during the rotation was obvious, the main assessors of the operation were not blinded. However, two professionals independently verified the scores to reduce bias.

Subjective evaluation

Students assess the improvement of their comprehensive capabilities and teaching satisfaction with an anonymous teaching quality questionnaire. The specific contents of the questionnaire can be found in the Appendix 1. The evaluation of comprehensive capabilities encompassed several dimensions: self-learning ability, the capacity to comprehend and apply theoretical knowledge, problem identification and analytical skills, teamwork proficiency, communication and expression skills, spatial imagination ability, clinical competencies, and overall self-comprehensive ability. Student evaluations, with each item rated out of 20 points, were assessed on a 4-point scale. A score ranging from 0 to 5 denoted no improvement, 6 to 10 indicated slight improvement, 10 to 15 reflected quite improvement, and 15 to 20 signified significant improvement. The levels of satisfaction regarding teaching quality were categorized into four distinct levels: dissatisfied, general, satisfied, and very satisfied. The students conducted the evaluation with three distinct components: the identification of teaching methods, the logical coherence of instructional arrangements, and the endorsement of educational tools. The satisfaction percentage was calculated using the formula: satisfaction = (number of ‘satisfied’ + ‘very satisfied’ responses)/total number of responses × 100%. Questionnaires were considered valid if they satisfied the following criteria: all items were fully completed without any missing data; no logical inconsistencies existed between different sections; submission occurred at the conclusion of the internship. Electronic questionnaires were programmed to ensure completeness, and manual verification was conducted by two independent researchers to ensure consistency.

The capacity for self-learning ability pertains to students’ ability to independently seek out literature and synthesize knowledge to address clinical challenges. The capacity to comprehend involves medical students’ capability to integrate foundational theories of cardiovascular surgery and apply them in clinical contexts. The problem identification and analytical skills encompass the ability to discern critical clinical issues and to formulate a series of differential diagnoses. Teamwork proficiency involves the effective allocation of tasks, the resolution of conflicts, and the achievement of consensus within group activities. Communication and expression skills refers to the proficiency in conveying medical information through clear oral presentations and well-structured written reports. Spatial imagination ability pertains to the capacity of medical students to dynamically construct, rotate, dissect, and identify target structures, such as heart valves and coronary artery branches, within 3D anatomical frameworks. This ability underscores the transformation from 2D representations to 3D entities and involves multi-perspective reasoning. The enhancement of clinical competencies pertains to the advancement of medical students’ practical competencies, as evidenced by their proficiency in standardized procedures, decision-making, and emergency management within simulated clinical environments. Meanwhile, overall self-comprehensive ability encompasses the holistic performance of medical students in synthesizing multi-dimensional skills to effectively tackle intricate clinical challenges.

Statistical analysis

The data analysis was conducted using SPSS 26.0. Continuous data are presented as mean ± standard deviation (SD), and intergroup comparisons were performed using analysis of variance (ANOVA). Data not conforming to a normal distribution were assessed using non-parametric tests, specifically the Mann-Whitney U test. Categorical data were described using frequencies and percentages, with comparisons made via the chi-square test. Statistical significance was determined at an alpha level of 0.05.

Results

Participants and research procedure

This study enrolled 80 students undertaking internships in the Department of Cardiac and Vascular Surgery at Hebei Medical University. All students had completed their clinical internships; 40 students were assigned to the digital teaching group and 40 to the C-P-TBL teaching group. The research protocol is depicted in Figure 10. The baseline characteristics of the two groups of students were well-balanced, as shown in Table 1.

Figure 10 Flowchart of the research protocol. C-P-TBL, case-, problem, and team-based learning.

Examination results

The students in the digital teaching group demonstrated significantly higher scores in theoretical knowledge assessment, clinical skills assessment, and overall performance compared to those in the C-P-TBL teaching group, with the differences reaching statistical significance (Table 2).

Comprehensive ability evaluation

In this study, a total of 80 electronic questionnaires were collected, all of which were deemed valid. Statistical analysis revealed that students in the digital teaching group outperformed those in the C-P-TBL teaching group regarding self-learning ability, comprehension and application of theoretical knowledge, problem identification and analytical skills, spatial imagination, and overall self-comprehensive ability. Nonetheless, no significant differences were observed between the two groups in terms of teamwork skills, communication and presentation skills, and clinical skills training (Table 3).

Teaching satisfaction evaluation

The findings from the questionnaire indicated that student satisfaction in the digital teaching cohort was 97.5%, whereas that in the C-P-TBL teaching cohort was 87.5%. The difference between these satisfaction levels was not statistically significant (P=0.20) (Table 4).

Discussion

Development status of clinical teaching of cardiovascular surgery

Cardiovascular surgery represents a pivotal and challenging component within the surgical clinical education framework. The intricate nature of cardiac anatomy, encompassing structures such as the atria, ventricles, valve complexes, aortic root, coronary circulation, and the cardiac conduction system (7), necessitates the integration of multidisciplinary theoretical knowledge alongside the management of significant surgical risks. Furthermore, a thorough understanding of the theoretical aspects of cardiac diseases forms the foundational knowledge base essential for medical students, enabling them to engage competently in various medical disciplines in the future. Currently, the predominant clinical teaching methodologies are primarily instructor-centered. Following comprehensive theoretical instruction, educators utilize resources such as anatomical atlases, imaging data, surgical videos, and other 2D visuals for explanatory purposes. Although the C-P-TBL model has supplanted the traditional LBL model and offered marked enhancements in addressing clinical issues, it remains restricted in fulfilling spatial visualization demands. This constraint contrasts with the erstwhile LBL model, which emphasized rote memorization of 2D anatomical illustrations. Neither of these two approaches can satisfy the highly demanding requirements of surgical clinical teaching that places significant emphasis on robust anatomy and complex operations.

This study demonstrates that the clinical skills assessment scores of the C-P-TBL teaching group were lower compared to those of the digital teaching group. Furthermore, in the theoretical examinations covering organ anatomy, disease classification, and treatment methods, the digital teaching group outperformed the C-P-TBL teaching group. Although digital technologies enhanced anatomical understanding and problem-solving, their impact on teamwork and communication may require targeted interventions. Educators should consider integrating team skill training (e.g., role-playing, conflict resolution) with digital tools to foster synergistic improvements in both technical and collaborative competencies.

Necessity and advantages of digital technology in clinical education of cardiovascular surgery

With advances in digital medical technology and the enhancement of intelligent digital environments, the transformation of medical education models increasingly incorporates augmented reality, virtual reality, mixed reality, 3D printing, artificial intelligence, and other emerging technologies. Consequently, a variety of teaching models, established since the Industrial Revolution, are anticipated to be supplanted by an innovative educational paradigm. This new model is characterized by its emphasis on personalization, employing blended learning methodologies and intelligent adaptive learning systems to facilitate individualized learning pathways for each student. In addition to focusing on the knowledge framework and actively engaging students’ subjective initiative, the instruction of cardiovascular surgery must also emphasize the enhancement of students’ spatial reasoning and operational skills. Labranche et al. (8) investigated the impact of spatial ability on the comprehension of 3D digital anatomical models. Their study demonstrated that a robust spatial ability facilitates students’ understanding and mastery of intricate 3D structures, which is particularly crucial in medical education, especially in the context of surgical training.

Currently, the development paradigm of cardiovascular surgery encompasses four primary directions: minimally invasive techniques, precision, rapid recovery, and intelligence. Over the past decade, minimally invasive technology has experienced significant advancements. Procedures such as complete thoracoscopic repair of atrial septal defects, ventricular septal defects, and anomalous pulmonary venous connections necessitate enhanced surgical precision and demand that surgeons possess a more profound understanding of organ anatomy (9). Owing to the limited incision size and restricted surgical field inherent in minimally invasive surgery, it is imperative for surgeons to maintain precision and ensure the safety of the procedure through meticulous technique and extensive anatomical knowledge. As minimally invasive technology continues to advance, surgeons must not only demonstrate proficiency in the utilization of surgical instruments but also possess a comprehensive understanding of the 3D architecture of organs, vascular distribution, neural pathways, and other intricate anatomical features.

We endeavored to enhance the clinical teaching model in surgery by integrating PBL, CBL, and TBL methodologies. This includes the implementation of simulation-based teaching guided by the principles of deliberate practice, as well as a blended approach combining online and offline instructional methods. The objective was to develop a more efficient and personalized teaching model. The study of heart disease necessitates a foundational understanding of anatomy, which requires comprehensive knowledge of systematic, regional, and sectional anatomy. This study integrates digital technologies, specifically advanced imaging and 3D printing, with pedagogical models such as PBL, CBL, and TBL. This integration not only enhances students’ intrinsic motivation but also develops their spatial visualization skills. Furthermore, it facilitates a deeper comprehension of diseases and surgical techniques, while also supporting the study of various organs. The majority of participants acknowledged the value of digital technology and perceived this educational approach as beneficial in enhancing their problem-solving and analytical skills, spatial imagination, and overall competency.

The questionnaire results of this study indicated that there were no significant discrepancies in teamwork, communication, and clinical skills capabilities. We consider the reason for this is that the teaching model employed by the C-P-TBL group inherently emphasizes teamwork through activities such as group discussions, case presentations, and role division, thereby systematically enhancing students’ collaborative and communication skills. Although the digital teaching group incorporated 3D printing and imaging technology, its collaborative framework remained largely unchanged. Furthermore, the self-assessment questionnaire utilized in this study may not have been sensitive enough to detect subtle differences in teamwork. Future research should incorporate objective indicators, such as team task completion efficiency and peer evaluations, to enable a more comprehensive, multi-dimensional assessment. No significant difference was observed between the two groups regarding “self-assessment of clinical skills” (16.58±2.707 vs. 16.05±2.230, P=0.27). However, the digital group demonstrated a significantly higher objective skill assessment (87.90±7.530 vs. 83.05±7.473, P=0.006). It is plausible that students’ self-assessment of skills is subject to self-perception bias, whereas objective assessments more accurately reflect operational competencies. Digital technology, through the use of 3D models, enhances anatomical understanding, thereby conferring an advantage in skill assessment. Nonetheless, students may not have fully recognized this improvement. The clinical skills assessment in this study concentrated on basic procedures, such as pericardiocentesis, which can be effectively acquired through standardized training. The potential benefits of digital technology may be more pronounced in the context of complex surgical planning, although this hypothesis necessitates further investigation through high-level research.

Improvement and prospect of digital technology in surgical clinical teaching

The integration of digital technology represents a crucial strategy for enhancing the quality of surgical clinical education (10). Nonetheless, the digital clinical teaching model for surgery in China remains largely in its exploratory phase. The majority of clinical teaching institutions have yet to engage significantly in this domain, and a systematic framework for the terminology and knowledge associated with digital teaching has not yet been developed. Nonetheless, this pedagogical approach necessitates a high level of guidance proficiency from educators in clinical instruction. It is imperative to enhance the training of educators’ digital teaching capabilities and to further refine the quality control mechanisms within clinical education. The advancement of digital surgical clinical education in China requires the establishment of a digital teaching and training platform, as well as a quality control center, grounded in the clinical medical big data center. Such infrastructure can significantly contribute to the subsequent standardization and enhancement of professional training quality for residents.

Conclusions

In this study, we sought to incorporate precision imaging and 3D printing technology into CBL, PBL, and TBL, and conducted evaluations focusing on knowledge acquisition, theoretical understanding, and clinical skill development. This initiative led to the preliminary optimization of a digital clinical teaching model for cardiovascular surgery, alongside the formulation of a personalized surgical clinical teaching plan aimed at enhancing students’ theoretical and practical competencies. Particular emphasis was placed on addressing clinical practical challenges and fostering improved spatial reasoning abilities. The initial investment required for a single 3D model, typically ranging from approximately 200 to 500 USD, can be efficiently amortized through high rates of reuse, resource sharing, and the long-term educational advantages it provides. Furthermore, the model’s capacity to deliver personalized and real-world scenario-based instruction is invaluable in augmenting clinical reasoning and practical skills. Meanwhile, it is essential to acknowledge the limitations in teamwork collaboration and teacher training. Multimodal assessment approaches, such as behavioral observation, can be employed in the future to guarantee the sustained enhancement of educational achievements.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CONSORT reporting checklist. Available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-98/rc

Trial Protocol: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-98/tp

Data Sharing Statement: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-98/dss

Peer Review File: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-98/prf

Funding: The study was supported by the Project of China Association of Higher Education (No. 23SZH0204); Ministry of Education Industry-University-Research Innovation Fund for Chinese Universities (No. 2024GY030); and Hebei Provincial Health Commission Medical Science Research Project (No. 20240183).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-98/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study received approval from the Research Ethics Committee of The Second Hospital of Hebei Medical University (No. 2024-C090). Prior to the commencement of the clinical internship, oral informed consent was obtained from participants. This consent process was documented in the questionnaire administered at the conclusion of the clinical internship, with the completion of the questionnaire serving as reaffirmation of the participants’ consent to partake in the study. The cardiac CT angiography data used for 3D modeling and printing were derived from anonymized clinical cases, with informed consent obtained from all patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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